A Real-World Lesson of How Information-Sharing Saves Lives

Learning in medical school is often likened to a fire hose aimed at your face.

Students, including myself, have so much medical information to digest, sometimes it really is just too much to handle. No single person can remember everything. We are so consumed by learning medicine that we often forget how we fit into the bigger picture of delivering care. Additionally, we are taught in a culture that values independence, confidence, intelligence, logic, and a respect for hierarchy. As students, this may be fine. But as time passes, this often morphs into self-centeredness, inflated egos, poor emotional intelligence, and frank disrespect for subordinates.

I recently had the opportunity to attend a patient safety roundtable hosted by Georgetown University and MedStar Health in Washington, D.C.

Conferences are usually not my cup of tea, but this one hit close to home. It showed us – nurses, pharmacists, students, and physicians – that patient safety is more than just rules, protocols, and checklists. True patient safety comes from changing our dysfunctional culture, improving the way providers communicate with each other and our patients, and remembering to put ourselves in the shoes of those we care for.

The Institute of Medicine’s landmark report To Err is Human indicated that 44,000 to 98,000 people die each year from preventable medical errors. This roundtable illustrated problems that can occur in our own backyard. All of us in D.C. were profoundly impacted by true stories of patients that our system has put at risk—some in which we have directly contributed to their death, all under the guise of “a complication has arisen.” Here is one of those stories.

On a Friday at the University of Illinois at Chicago, a Spanish-speaking woman had begun chemotherapy treatment for her cancer. The following weekend she developed difficulty breathing, fever, mild chest pain, and significant coughing. On Monday morning, she decided to go to the ER where she received a chesty x-ray and basic labs. It was determined she indeed had pneumonia. Since her labs had shown a low white blood cell count in addition to knowing she had cancer, she was admitted.

As the ED physician requested a consult, an oncologist arrived to see her later that Monday. Utilizing a certified translator, he tells the patient that since she is in the hospital anyway, they’ll administer chemotherapy.

The oncologist arrives the next morning on Tuesday to find that she is complaining of digestive issues, skin irritation, and mouth sores. Her situation eventually progresses to total-body skin sloughing, diarrhea, vomiting, and gum bleeding – just to name a few. Even the oncologist is surprised by such a severe reaction to treatment, and the patient experiences massive discomfort and pain for the next several days. The oncologist reports the situation to the hospital safety officer, and an informal investigation ensues.

It was discovered that the patient received an improper double dose of chemotherapy. This occurred because the University’s ambulatory and outpatient systems did not interface, and the oncologist did not know the patient had received the initial dose only three days prior. The patient thought that this was standard procedure, as the initial treatment plan wasn’t properly communicated to her.

The safety officer, who is also a physician, urges the oncologist to talk his patient about the error and how it occurred. The oncologist was adamantly opposed to this level honesty, especially since she recovered and is otherwise doing well. However, the safety officer had instituted a new program at the University earlier that year that promoted transparency and honesty. The oncologist eventually agrees and the two physicians explain to the patient how events had unfolded.

Expecting that she would be extremely upset, they were extremely surprised when she and her daughter began smiling. After they made some comments to each other in Spanish, the daughter turns to the oncologist and says, “Thank you for telling us. We thought that this was a normal response to chemotherapy. My mom was ready to stop treatment, go home, and live out the days she had left. You saved her life.”

There are many lessons to be learned in that story. From system failures and information sharing to the culture of physicians and the concepts of patient safety and transparency, stories like this illustrate just how frequently preventable medical errors occur.

As a lesson to you, the reader and a patient, never hesitate to ask questions, to communicate, and to become involved in the conversation about your care.

To providers, ask yourself, “Why do we do things this way? Would I want a doctor to not tell me the truth?”

To those in health IT, this illustrates the real impact of information on not just the quality of care, but also perhaps whether or not someone lives.
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